12755 SW 128TH AVENUE-1 •
AVENUE12755 SW 128TH
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AD0RES5,�?j5`�;_ .� 7x PERMIT NO
PERMIT CHARGE none
OWNER4
CONNECTIONEE
PAID BY
TYPE OF BUILOING a1!�., DATE CONNECTED
SrRVICE RATE INSPECTION FEE � _�
CONTRACTOR � P A 10 BY , DATE
SIZE OF CONNECTION A35ESSMLNT PAID
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t"ID OREGON
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0��ner:...........Ja.y..Miller ........ .................................Permit No...10.78...._
�s Building Address..... ......... 12755. SW_128.th......:..-...._.. ... ......-.....
' Certificate i� hereby given this........4......day of.........Panua•ry........ 111 77
that ,aid building may be occupied and
r � chat it complies m ith all reyuir.-ments of
the Building Code for the City iJ Tigard, • ;�
as apps ived by the Tigard City Council.
3 iil. �. Cyd' 9�1",•�'�.. .�..... ..r'.!'i(���' �....... ...... '�� ',11 ''•
nuimine Inspector
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City of Tigard I
INSPECTION REQUEST
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for
INSPECTION TIME: 1t PERMIT NUJ. :
DATE: ' � �� 'L- DATE I;a S U E D _._1_L_
OWNERS NAME — --- --- --
ADDRESS: --_ -- -- - — I
CONTRACTOR : __—_ --- I
TEST '. Air 0, Water(3 Vieua1 [3 , Lobo ratory ❑ I
RESULT: Approved I , Disapproved C. Pending Q,
SKETCH: I
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INSPECTOR DATE I
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BUILDING PERMIT APPLICATION coF TIGARD DATE 9-21-76 _, 19
625-6562
THE UNDERSIGNED HEREBY APPLIES FOR APERMIT FOR THE WORK HEREIN INDICATED 13UIL.DERPHONE.;,aap —
OR AS SHOWN AND APPROVED IN THE ACCOMPANYING PLANS AND SPECIFICATIONS. OWNERPHON97 l
LOT NO.
Jay i,iiluk' 12755 SW 1,%, t,,l
OWNER J(.)B ADDRESS HOME ADDRESS
ARCHITECT
M1.11ar h Sona ENGINEER
BUILDER ADDRESS❑ DESIGNER, _-
_STRUCTURE ANEW ❑REMODEL ADD!TION ❑_REPAIR ❑ ❑
_RENEWAL rIREDAMAGE ❑DEMOL.ITION
6 RESIDENCE ❑COMM ❑EDUCATIONAL ❑GOV'T ORE LIGIOUS❑PATIO ❑CAR PORT ❑GARE,GE ❑STORAGE❑°LAB ❑FENCE
❑BOND ❑MOVING ❑CONDITIONAL- USE ❑DESIGN RL-VIEW ❑COUNCIL APPROVED ❑SIGNS
OCCUPANCY--LAND USE ZONE_ BLDG. TYPE .FIRE ZONE PLAN CHECK BY -- _ HEAT_
Conste single family dwcllin(,a w/Fattachao garat.1ii 3 oudraam 2 br)th
Tax map 2S1-4AD Tax L at t,1':tali ----
1 1360 - A(-�01.
OCC. QAV___ AREA _ DRQQMS VA
BUILDING DEPARTMENT ?" 1..
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SET BACKS FRItNT REAR LEFT SIDE RIGHT SIDE
Pftrmlt
-"'"— THIS PERMIT IS ISSUED SIJBJECT TO THE PEGULATIONS CONTAINED IN THE BUILDING CODE. ZONING
Pia, Check REGULATIONS AND ALL APPLICABLE CODES AND ORDINANCES, A'JD IT IS HEREBY AGREED THAT THE
—� WORK WILL BE DONE IN ACCORDAP,!C E WITH THE PLANS AND SPECIFICATIONS AND IN COMPLIANCE WITH
Sub-total ALL APPLICABLE CODES AND OR!)INANCES THE ISSUANCE OF THIS PERMIT DOES NOT WAIVE
RESTRICTIVE COVENANTS. CONTRACTOR AND SUB CONTRACTORS To HAVE CURRENT CITY BUSINESS
State Tax ---�� — LICENSE. SEPARATE PERMITS REQUIRED FOR SEWER PLUMBING AND HEATING.
Total 242.-5 -
RV --- --- –_----------
AP ":ANT OR AGE-NT
Approved ------ HI'r.eil)t No
ADDRESS PHONE
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UNIFIED SEUERAGE AGENCY NO. 10648
W�SIA I NGTON COUNTY DATE ____ 9-21-76
CITY OF...____-- Tigard
APPLICATION FOR SEWER CONNECTION PERMIT
Jay (Miller
OWNER: __ _�_..._.__..
G'JUNER'S ADDRESS:_-__.
STREET
CITU 21P
BUILDING SITE: LOT------__ BLOCK __ ADDITION
R Tax I'?ap 251-6AD residence
TAX LOT N0. ._1C10__� .___._ TYPE OF O1CUPANCY- �___
ADDRESS _ 12755 SU 1;28th
DWELLING UNITS FIXTURE UNITS
SURCHARGE IF APPLICABLE
PERMIT FEE 5'l5. DO _� INSPECTION FEE ._ OD. TOTAL DEPOSITED 600. 00
(NEW) (EXISTING) BUILDING SEWER SYSTEM . .._..._._Fanno Creek
The Anplicant agrees to comply with all rules and regulations of the Unified Sewerage Agency.
APPLICANT ,
SL=WER PERMIT
THIG PERMIT AUTHORIZES CONNECTION TO THE SEWER SYSTEM.
LINE SIZE ._._._- . .__ ._._ ._ .__. . __ INSTALLER .._..___-
RECEIVED BY. A
W7,
p ENCY OR 175 AGENT)
COMMENTS c;;,, 1 p;S 1 �,O. CIO L,r o n
This Application and permit expires in one hundred and twenty (120) days.
The amount paid will be forfeited should expiration occur.
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